2018 Benefits Program Qualifying Event Change Form
Employee ID__________ (Required) 1 2018 Benefits Program Qualifying Event Change Form Please Print - Please Complete ALL Applicable Sections If you have any questions, please contact the University of Rochester Office of Total Rewards at (585) 275-2084 or (585) 272-0227 Please return completed forms to: Office of Total Rewards, 60 Corporate Woods, Suite 310, Box 270453, Rochester, NY 14627; Fax: 585-272-0227 or Email: Employee Information Name (Last, First, Initial) Please Print: ________________________________________ ____________________________________ Address: ________________________________________ ________________________________________ ____________________ ________________________________________ ________________________________________ ____________________ Gender (M/F): _______________ Date of Birth (MM/DD/YYYY): _________________ Phone Number: ______________________ E-mail Address: ________________________________________ ________________________________________ _______________ Marital Status: Single Married Widowed Divorced Please Check Desired Acti
This section must be completed for any request to change University Health, Dental, or Flexible Spending Account elections outside of the annual open enrollment period due to a qualifying event.
Download 2018 Benefits Program Qualifying Event Change Form
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